NAVIGATING THE MAZE—Perinatal Exchange

Risk, Safety, and Choice in Childbirth

Judith A. Lothian, PhD, RN, LCCE, FACCE

ABSTRACT
In this column, the author explores current understandings of risk and safety in pregnancy and childbirth.
An emphasis on risk management places the provider and hospital in control of women’s decisions related
to pregnancy and birth and may make pregnancy and birth less safe for mothers and babies. Accepting that
no life is risk free, women can let go of fear and make choices that take into account real, not imagined, or
exaggerated risk and, in doing so, increase safety for themselves and their babies. The focus of maternity care
becomes enhancing safety through evidence-based practice rather than managing risk.

The Journal of Perinatal Education, 21(1), 45–47, http://dx.doi.org/10.1891/1058-1243.21.1.45

Keywords: risk, safety, choice, childbirth, pregnancy

“Better safe than sorry” seems to drive women’s
childbearing choices. Choices related to care pro-
vider, place of birth, prenatal testing, what foods
to avoid, eliminating all caffeine, alcohol, and
over-the-counter medications, how much and what
kind of exercise, and whether and when one can
safely travel, just to name a few, make pregnancy a
full-time, stressful job. Women go through pregnancy
worried for their babies and themselves. Rothman
(2001) notes that Dutch midwives describe prenatal
testing as “­spoiling the pregnancy.” Every risk, how-
ever small, is discussed and, too often, exaggerated.
Obstetricians have convinced women that managing
risk is the key to safety in pregnancy and childbirth.
But, is it?
PERSPECTIVES ON RISK
Merriam-Webster’s Collegiate Dictionary (2008) de-
fines risk as a possibility, a chance. Slovic (1987) notes
that society is safer now than at any time in ­history,
but there is increasing concern with risk and a societal
desire to have a risk-free life, which is an ­impossibility.
Slovic’s research focuses on ­perceptions of risk from
an individual and societal perspective, asking the
question “What is ­acceptable risk?” And the answer
to that question changes ­depending on whose risk we
are talking about and the particular circumstances.
DeVries (1992) describes that the common
­strategy of professional groups gaining control is to
create risk or exaggerate risk. One way groups gain
power is by reducing risk and uncertainty. Where
there is limited risk, it can be “created” by redefin-
ing ordinary life events as risky and emphasizing
whatever risk ­exists. The medical model of birth en-
courages women to see birth as inherently risky for
mother and baby ­(DeVries, 1992; Rooks, 1997), tak-
ing ­advantage of women’s normal fears for themselves
and their ­babies. The obstetrician is then in the pow-
erful ­position of reducing the risk and ­uncertainty.
During pregnancy, women are advised and cau-
tioned about ­every conceivable, however small, risk;
but interestingly, when it comes time for the birth,

Risk, Safety, and Choice in Childbirth  |  Lothian 45

What is acceptable risk for the mother and her baby may indeed
not be acceptable risk for the obstetrician or hospital.
there is little, if any, ­discussion about the risks of rou-
tine interventions, such as continuous electronic fetal
monitoring, elective induction, and epidurals.
The consequences of creating, exaggerating, and
managing risk in pregnancy and childbirth include a
33% cesarean rate, an ever increasing induction rate,
and neonatal intensive care units filled to capacity.
It has led to pregnancies fraught with worry, an ever
increasing fear of labor and birth, and a reluctance
of women to make choices that reflect putting risk in
perspective and ­deciding for ­themselves what “accept-
able” risk is. Women are ­especially reluctant to make
decisions that go up against the system or against
“medical advice” ­(Cartwright & Thomas, 2001).
What is acceptable risk for the mother and her baby
may indeed not be acceptable risk for the ­obstetrician
or hospital. Although women are led to believe that
maternity care is designed to manage (reducing risk
and uncertainty) the risks for mother and baby, in
fact, the risks for the obstetrician and the hospital
drive practice in ways that most women are unaware
of. The overuse of technology and ­testing, induc-
tions, and cesarean surgeries are just a few ­examples
of practices that decrease the risk of litigation for
physicians. Interestingly, there is increasing evidence
that the risk of litigation, like risk, is also exaggerated
(Cartwright & Thomas, 2001). While during preg-
nancy the obstetrician in addition to routinely using
technology (e.g., frequent ultrasounds) and increas-
ing numbers of prenatal tests, it is once labor starts
that there is a shift from managing maternal and fetal
risk to managing obstetrician and hospital risk. The
result is intervention intensive labor and birth.
The more we focus on risk, the more fear we ­create
and the less able women are to trust their bodies, the
beautifully designed process of pregnancy and birth,
and their ability to give birth. The less women trust
themselves, the more vulnerable they become and
the less able they are to make sensible decisions for
themselves and their babies. It is not a surprise that
women resort to “better safe than sorry” as a guide
to decision making. But does managing risk, the
woman’s or the obstetrician’s, make things safer?
Managing small (or exaggerated) risk can ­actually
increase risk. A classic example of this is that the
routine use of electronic fetal monitoring increases
the risk of a cesarean but is no safer for the baby
46 The Journal of Perinatal Education  |  Winter 2012, Volume 21, Number 1
than intermittent auscultation of the fetal heart rate
­(Alfirevic, Devane, & Gyte, 2006).
PERSPECTIVES ON SAFETY
Safety is defined as a condition of being out of harm’s
way, protected, careful, cautious, not ­dangerous
(Merriam-Webster’s Collegiate Dictionary, 2008).
Safety for individual mothers and babies is more
than medical safety. Is birth inherently dangerous?
Can it ever be risk free or danger free? No.
Sandall (2011) notes that in the current ­maternity
care system, women are the “risk creators” (genes,
disease, lifestyle) that obstetricians need to ­manage.
The safety focus of the Institute of Medicine’s (2001)
safety initiative is, by contrast, to make the system
safer. It is the risk in the system that needs to be
managed. Sandall suggests a broader definition of
safety that moves beyond risk reduction focused on
the women to evidence-based care.
There is a wealth of research that provides
­evidence for best practice in pregnancy and child-
birth; however, in the United States, evidence-based
practice is not the norm (Sakala & Corry, 2008).
Lamaze International’s six Healthy Birth Practices
(Lothian, 2009) provide a summary of best practices
that is an important resource for women and their
families. The Cochrane Library is an excellent source
of systematic reviews and guidelines for evidence-
based practice. The research findings are clear. It is
dangerous to interfere in the normal, physiologic
process of birth without a clear medical indication.
Perhaps the biggest threat to safety is techno-
cratic, fragmented, depersonalized care. Edwards
(2011) describes the kind of safety provided by
small-scale midwifery practices. It is the kind of care
that “engages women’s hopes, aspirations, concerns
and fears and in doing so builds trust, so women can
focus on well being and avoiding harm” (p. 21).
MAKING CHOICES THAT REFLECT REAL RISK
AND ENHANCE SAFETY
Where does all of this leave women? Sandall (2011)
suggests moving beyond the typical “Tell us what
you like and we will do what we think is best” to
­encouraging women to make autonomous decisions
about what is best for themselves and their babies.
What stands in the way of this happening?
There is a moral dimension to not following rules
and ­protocols, and this puts enormous pressure on
women to conform and not rock the boat. There
is a moral imperative to follow established ways of
doing things and to buy into the societal view that
­ anaging risk improves outcomes. If a woman
m Navigating the maze of risk and safety in maternity
chooses something different, for instance ­home
birth, refusing to be induced or opting out of prena-
tal ­testing, the powerful obstetrician counters with
“You are ­endangering your baby.” It is a rare woman
who has the confidence to refuse to comply.
Informed decision making requires knowledge and
support, and childbirth education can provide both.
Childbirth education can help women put risk in per-
spective and develop a deeper understanding of the
relationship between evidence-based care and safety.
CHILDBIRTH EDUCATION
It is important that women in childbirth classes un-
derstand that a risk-free life does not exist. It is also
essential to remind women that they construct and
manage risk every day. We can help women sort out
the ways in which they do this in their everyday lives.
It is risky to fly in a plane or drive a car. Which is
most risky? The car, but most of us drive every day.
What is the real risk of having an occasional glass
of wine in pregnancy? The examples are endless. We
need to be careful not to jump on the medical train
that puts the onus on the woman to reduce risk:
don’t eat unpasteurized cheese, avoid all alcohol and
caffeine, take prenatal vitamins, get a flu shot.
It is important that we spend time discussing
the differences between risk and safety and ­making
it clear that the current maternity care system
­increases risk and makes birth less safe for mothers
and babies. Women need to know the care practices
that make birth safer for mothers and babies and the
practices that do not.
Childbirth educators need to take a strong stand in
support of changing the system to increase safety for
mothers and babies. Women need to know there is an
inherent, simple wisdom in nature’s plan for birth. Is
there potential danger? Yes. But we can ­minimize the
danger with knowledge, with confidence, with being
able to avoid unnecessary medical interventions, by
being healthy in general, by letting labor start on its
own, by working with contractions rather than im-
mediately having an epidural, and by opting out of
elective induction and cesarean ­unless there is a clear
medical indication. In the current ­maternity care sys-
tem, choosing “better safe than sorry” is risky. It is a
reasonable guide only if women know that the care
they are receiving is evidence based.
Safety is not about frantically trying to minimize
small or exaggerated risks during pregnancy and then
giving birth in hospitals that protect ­obstetricians’
­interests while increasing risk for mothers and ­babies.
Risk, Safety, and Choice in Childbirth  |  Lothian
W
The Lamaze Six Healthy
care is daunting. Childbirth educators can make a Birth Practice papers can be
difference by ensuring that women are confident in accessed at http://www.
their own ability to give birth and knowledgeable lamaze.org
about safe, evidence-based care.
REFERENCES
Alfirevic, Z., Devane, D., & Gyte, G. M. (2006). Continuous
cardiotocography (CTG) as a form of electronic fetal
monitoring (EFM) for fetal assessment during labour.
Cochrane Database of Systematic Reviews, 3, CD006066.
http://dx.doi.org/10.1002/14651858.CD006066
Cartwright, E., & Thomas, J. (2001). Constructing risk: Ma-
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Journal of Perinatal Education, 18(3), 48–54. http://
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Rooks, J. P. (1997). Midwifery and childbirth in America.
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Sakala, C., & Corry, M. P. (2008). Evidence-based ­maternity
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­maternity-care.pdf
Sandall, J. (2011, May 26). Re-framing safety: Risky health
systems and safer childbearing. Presentation at Fear and
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Creating Risk in Pregnancy and Childbirth ­symposium,
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JUDITH A. LOTHIAN is a childbirth educator in Brooklyn,
New York, chair of the Lamaze International Certification
Council, and the associate editor of The Journal of Perinatal
Education. She is also an associate professor in the College
of Nursing at Seton Hall University in South Orange, New
Jersey.
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